Forward Momentum: It’s time for an Age Friendly Health System€¦ · It’s time for an...

Forward Momentum: It’s time for an Age-Friendly Health SystemKedar S. Mate, MDChief Innovation Officer, IHI

October 19, 2017

Situation (1):

Older adults:

• do not reliably receive necessary and evidence-based care;

• routinely receive unwanted care and treatment when we don’t know

what matters to;

• are needlessly harmed by inappropriate medications; .

• are vulnerable to falls when we don’t encourage mobility;

• experience avoidable delirium and cognitive decline.

4©2015

Source:

SEMCOG 2040 Forecast-14.0% -11.4% -11.0%

85.5%

-20.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

0-17 18-24 25-64 65+

Population Growth by Age Group 2010-2040

Counties Included

in Data Set:

• Livingston

• Macomb

• Monroe

• Oakland

• Washtenaw

• Wayne

Situation (2):

Situation (3):

• We have lots of evidence-based geriatric-care models of

care that have proven very effective

Bettercareplaybook.org 6

Situation (3):

• We have lots of evidence-based geriatric-care models of

care that have proven very effective

• Yet, most reach only a portion of those who could benefit

– Difficult to disseminate and scale

– Difficult to reproduce in settings with less resources

– Most don’t translate across care settings

• 4m of 46m

The Know-Do Gap

Yesterday Today Tomorrow

What we

know

What we

do

“The First Law of Improvement”

Every system is perfectly designed to

achieve exactly the results it gets.

Dr. Paul Batalden

To get a different result, we must

change the system

Model I: Bad Apples

The

Problem

Quality

Frequency

Better

The Simple, Wrong Answer

Name, Shame & Blame

Somebody

The Cycle of Fear

Engender

Fear

Micromanage Kill the

Messenger

Filter the

Information

Model 2: Continuous Improvement

“All teach, All learn”

Quality

Fre

qu

en

cy

“…98,000 people die in

hospitals each year as

a result of medical

errors that could have

been prevented.”

Institute of Medicine,

November 1999

Origins of the 100,000 Lives Campaign

• By 2004, as a country we had made little progress

• The science was available, our implementation was

unreliable

• Variability in the quality of care was persistent &

entrenched

• There were isolated islands of excellence in patient

safety

• We believed that our sense of urgency was shared by

leaders and providers everywhere in healthcare

100,000 Lives Campaign Objectives (December 2004 – June 2006)

• Save 100,000 Lives

• Enroll more than 2,000 hospitals in the initiative

• Build a national infrastructure for change

• Raise the profile of the problem - and our

proactive response

Six Changes That Save Lives

• Rapid Response Teams

• Evidence-Based Care for Acute Myocardial

Infarction

• Medication Reconciliation to prevent Adverse

Drug Events (ADEs)

• Apply Central Line Infection Bundle

• Prevent Surgical Site Infections

• Apply Ventilator-Associated Pneumonia Bundle

Over 3,100 Hospitals Enrolled

78% of all acute care beds

“When we talk of social

change, we talk of

movements, a word that

suggests vast groups of

people walking together,

leaving behind one way and

traveling toward another.”

Rebecca Solnit

Roadmap for a movement

• Will for change

• Aim & Purpose

• Evidence-based

interventions

• Technical method

for change

• Social system for

spread

What is our aim?

The John A. Hartford Foundation and IHI have

adopted the bold and important aim of establishing

Age-Friendly Care in 20 percent of US hospitals

and health systems by 2020

An Age-Friendly Health system is one where every

older adult:

• Gets the best care possible;

• Experiences no healthcare-related harms; and

• Is satisfied with the health care they receive.


• Will for change

• Aim & Purpose

• Evidence-based

interventions


for change


spread

Deriving the Evidence-based interventions

• Reviewed 17 evidence-based models and

programs serving older adults:

– What population is served?

– What outcomes were achieved?

– What are the core features of the model?

July – August 2016

90 discrete core features identified by model experts in pre-

work

Redundant/similar concepts removed

and 13 core features synthesized by IHI

team

Expert Meeting led to the selection of the “vital few”: the 4Ms

29

The Four M’s

• What Matters: Knowing and acting on each

patient’s specific health goals and care preferences

• Medication: Optimizing medication use to reduce

harm and burden, focused on medications affecting

mobility, mentation, and what matters

• Mentation: Identifying and managing depression,

dementia and delirium across care settings

• Mobility: Maintaining mobility and function and

preventing complications of immobility

Evidence-base

• What Matters:– Asking what matters and developing an integrated systems to address it lowers

inpatient utilization (54% dec), ICU stays (80% dec), while increasing hospice use (47.2%) and pt satisfaction (AHRQ 2013)

• Medications:– Older adults suffering an adverse drug event have higher rates of morbidity, hospital

admission and costs (Field 2005)

– 1500 hospitals in HEN 2.0 reduced 15,611 adverse drug events saving $78m across 34 states (HRET 2017)

• Mentation: – Depression in ambulatory care doubles cost of care across the board (Unutzer 2009)

– 16:1 ROI on delirium detection and treatment programs (Rubin 2013)

• Mobility: – Older adults who sustain a serious fall-related injury required an additional $13,316 in

hospital operating cost and had an increased LOS of 6.3 days compared to controls (Wong 2011)

– 30+% reduction in direct, indirect, and total hospital costs among patients who receive care to improve mobility (Klein 2015)

References at end of slides

31

4Ms, high level interventions and implementation actions

32

High-level Interventions Implementation Actions

What

Matters

1

Know what matters: health outcome goals and

care preferences for current and future care,

including end of life

Developed with the health

systems teams.

Teams can select from our

ideas or identify their own

ideas for reliable

implementation.

We will learn from one another

and share generously.

2Act on what matters for current and future care,

including end of life

Mobility

3 Implement an individualized mobility plan

4 Create an environment that enables mobility

Medicatio

ns

5Implement standard process for age-friendly

medication reconciliation

6 De-prescribe and adjust doses to be age-friendly

Mentation

7Ensure adequate nutrition & hydration, sleep and

comfort

8Engage and orient to maximize independence

and dignity

9Identify, treat, and manage dementia, delirium,

and depression


• Will for change

• Aim & Purpose

• Evidence-based

interventions


for change


spread

The Model for Improvement


• Will for change

• Aim & Purpose

• Evidence-based

interventions


for change


spread

Design to Achieve National Scale

Stage 0:

Developin

g the

Prototype

Activity: Literature

review & Expert

meeting

Output: Age

Friendly Prototype

Stage 1:

Testing

the

Prototype

Activity: Prototype

testing with five

systems & scaling

within those five

Output: Age Friendly

Model & Scale-up

Guidance

Stage 2

Scale-Up

Activity: Campaign

spreads to 1000+ care sites

Output: 1000+ Age Friendly

Health Systems with

evidence of improved

outcomes for older adults

Testing the Prototype for refinement

(3/17 – 2/18)

Scaling up the Prototype in the five

prototyping systems (1/18 – 12/18)

Where are we now?

38

By the numbers…

• 5 systems actively testing across 26 sites (primary care, PACE, outpt hospice, SNF, inpatient acute, rehab, CCRC, senior ED) in 8 states

• 17 Advisory Group members (chaired by Mary Tinetti & Ann Hendrich)

• 9 expert geriatric faculty – the leaders of the field

• 60+ active tests executing now of age-friendly

• 214 members of AFHS list-servs (US and abroad)

• “Thousands” of lives improved…our most recent estimate was over 3500 in early testing

A 95 year old woman

40

Developing “change packages” for Age-Friendly Care

M Prevent Assess Treat

What

MattersDocument health care

agent

Ask What Matters

questions and document

responses; Ask for

presence of health care

agent

Apply What Matters in

treatment

Medication

Remove in-hospital meds

from discharge med list;

Send updated med list to

primary care physician;

change order sets

Screen for high-risk

meds

De-prescribe or dose

adjust high-risk meds

(especially opiates,

insulin, sleepers)

Mentation

De-prescribe meds

known to cause delirium;

Ensure sufficient

hydration; Support

sufficient sleep

Screen for delirium

(e.g., 2 questions)

Identify and reverse

causes of delirium (non-

pharmacologic); plus

Prevention

Mobility Mobilize patients (if

ambulatory; if not

ambulatory)

Conduct mobility test

(e.g., TUG)

Create mobility plan; plus

Prevention

If found

If positive

If positive

A sample of tests being run by our

health system teams1. Glacier Hills: Moving to single document, work flow,

documentation of What Matters conversation

2. Glacier Hills: Education of providers about asking What Matters

questions using Being Mortal film

3. St. Alphonsus: What Matters Most to You flyer

4. St. Alphonsus: Testing Serious Illness Conversation Guide

questions

5. St. Alphonsus: Asking What Matters questions in Assessment

Bundle

6. St. Alphonsus: Moving advance care planning documents/

advanced directives to the next level/site of care or provider at

discharge

7. St. Mary Mercy: Integrate What Matters questions into geriatrics

assessment

8. Providence: Testing Scotland What Matters questions

9. KP: Knowing older adults through “My Care My Life” binder

10. Ascension: Assessing caregiver burden with caregivers and

patients

11. Ascension: Information on website about services and to enable

self-referral

12. Ascension: Streamlined patient access Referral and intact process

13. St. Alphonsus: Bring home med containers to AWV for better med

rec

14. St. Alphonsus: Checking home meds with provider profile in EMR

with every admit

15. St. Alphonsus: Obtaining med list from pharmacy to review for

deprescribing

16. St. Alphonsus: Education guide based on Med Rec Guide

17. St. Mary Mercy: Medication review for pill burden and sending

deprescribing recommendations to pharmacy

18. Providence: PharmD reviews med list for high risk meds and

recommends de-prescribing to PCP

19. PACE: Pharmacovigilance review with ER/hospital utilization

review

20. Anne Arundel: Established an Age-Friendly prescribing “culture”;

Looking for opportunities to scale-up to other units

21. KP: Patients encouraged to bring personal items to hospital to

create a “Just like home” environment

22. KP: Coaching for staff to develop personal relationship with pts

23. KP: Educate providers re medication issues for deprescribing and

treatment of delirium

24. KP: Self-care plan for high-risk patients, case manager creates

plan to include hydration and nutrition

25. Glacier Hills: Screening (bCAM), standard intervention for

delirium

26. St. Alphonsus: Assessment with mini-cog and PHQ2

27. St. Mary Mercy: Communication re 3D delirium assessment

28. St. Mary Mercy: Assessment with family member involvement

29. Anne Arundel: Hydration- geriatric cups

30. Glacier Hills: Assessment tool with what matters most about

mobility

31. Glacier Hills: Workflow, PT referral to wellness center, education

32. St. Alphonsus: Timed Get Up and Go assessment

33. St. Mary Mercy: Matter of balance, check your risk for falling

(CDC) plus meds

34. St. Mary Mercy: Story book, shorts, What Matters document,

thank you letters, MOVE (mobility optimizes virtually everything)

35. Providence: STEADI results at annual wellness visit, patient who

has fallen or with specific STEADI score has follow up visit with

RN to address risk factors

36. Providence: Measure mobility with STEADI scores at AWV year-

over-year

37. Providence: Patient who has fallen or with specific STEADI score

participate in a shared medical appointment; PharmD reviews

med list for high risk meds and recommends deprescribing to

PCP

38. KP: Patient-initiated patient mobilization, MD's provide 1-page

prompt with exercises (includes exercises for patients in bed and

wheelchair)

39. Anne Arundel: Mobility/quality tech

40. Anne Arundel: 6-clicks, refer to PT

Practical ideas for changing the system of production43

0

500

1000

1500

2000

2500

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

Hydration

Water Intake w/ Old Pitcher Median

73% increase

Knowing & Acting on What Matters44

Reduced

falls by 18%

Mobility: Empowering older adults 45

Reduce Length of

Stay;

Go home not rehab

FY18 APPROVED System Level Performance Measures / Metrics

Goal Area/Weight Measures Level* Threshold Target Maximum Comments

1. Community Health & WellBeing (CHWB) / 20%

75% of the 20% weight (i.e., 15%):Clinical Services: Tobacco and BMIScreening and Referral Improvement (2points available)Clinical Transformation Portfolio (8 pointsavailable)

System Level 4+ points 7+ points 9+ points Clinical Services: Each ministry has an individual baseline and individual targets. Points earned based on improvement.Clinical Transformation Portfolio: Five policy, system and environmental change strategy initiatives

25% of the 20% weight (i.e., 5%) Growth

System Level TBD TBD TBD New dimension for FY18 to be developed

2. Clinical Care / 20% Reduction of unplanned 30 dayreadmissions to acute inpatient TrinityHealth facilities

(50% of the 20% weight)

System Level 40% of ministries at Target or better

50% of ministries at Target or better


For reference, FY17 = 30/40/50 % of ministries at threshold or better

Reduction of Hospital Acquired Infections(50% of the 20% weight)

System Level 40% of ministries at Target or better




3. Patient Experience / 20% Willingness to Recommend:Acute Care (34% of 20% weight)Emergency Care (33% of 20% weight)Owned physician practice groups CG-CAHPs (33% of 20% weight)

System Level 30% of ministries at Threshold or

better

40% of ministries at Threshold or

better

50% of ministries at Threshold or better


4. Colleague Engagement /20%

Colleague Engagement Score System Level 4.06 4.08 4.09 For reference, FY17 = system level score of 4.03/4.05/4.09

5. Financial Stewardship /20%

Operating Margin (OM) (50% of the 20% weight) Cost Per Case Mix-Adjusted Equivalent

Discharge (CMAED)(50% of the 20% weight)**

System Level

System Level

OM: 1.5%

Cost Per CMAED: $7,806

OM: 2.1%


OM: 2.6%


For reference, FY17: 1.2/2.2/3.0 % OM

For reference, FY17: $7,720/$7,645/$7,570 Cost Per CMAED

**Reflects our overall cost position and actions to improve this cost position to move on glide path to be profitable under Medicare. This Cost per CMAED is based on Regional Health Ministries (RHMs) only. For National Health Ministries and Mission Health Ministries, cost per unit metrics will be:Trinity Health Senior Communities (THSC): Cost per DayTrinity Health at Home (THAH): Cost per AdmissionTrinity Health PACE: Cost per Member per MonthPittsburgh Mercy Health Services: Cost per Outpatient UnitAll other Mission Health Ministries: No cost metric; Operating Margin used as the sole measure of financial stewardship Note: The same spread applies to National Health Ministries and Mission Health Ministries

*For RHM executives, weight on objectives is split between an RHM (70%) and System (30%) Components

46©2017 Trinity Health

FY 18 Priority Strategic Aims – These are the priorities!

↑ mob, ↓ hi risk meds & know what matters ↓ ADEs,

right-siting care, ↑ functional status ↓ unplanned

admissions

↑ mob & know what matters

↑ functional status, ↑ d/c to home, ↑ HCAPHS

↑ willingness to recommend

Mechanism varies by discounted FFS, Per case (DRG),

APM (provider at risk)

The business case

Make a sustainable

business case for age-friendly care

Reduce costs associated with

poor quality care

Reduce harm that results in use of higher level of care settings, longer inpatient LOS, ED visits,

readmissions to inpatient settings

Reduce risk of malpractice claims

Improve care transitions, discharge planning, and care coordination

Increase utilization of cost-effective

services

Increase consistent use of underused, evidence-based services and practices

Reduce over-utilization of unnecessary care

Optimize site of care (shift care to lower cost care settings)

Enhance revenue and market share

Increase staff productivity and decrease turnover

Increase bed capacity

Improve reputation as an AFHS to attract patients

The risk…and the opportunity

• Motion…

• Or we could get what Elon Musk described as

“the sum of all vectors”—what you call

FORWARD motion

48

“Every person in your

company is a vector.

Your progress is

determined by the sum

of all vectors.” —

Elon Musk

• Build a shared understanding of the problem

• Set “winnable milestones”

• Design approaches that will work at massive scale

• Drive (rather than assume) demand

• Embrace course corrections

Forward

Motion

What can we do by next Tuesday?50

What can we do by next Tuesday?51

This is our moment. It is time for an Age-Friendly system of care that touches every single older adult in this country.

• Talk to your local hospital CEO or Board chairperson about what it would take to become Age-Friendly

• Ask them to commit to one action—to one “M”—to becoming more Age-Friendly starting next month

• Tell them you will support them to realize it

• And…tell us about it so we can learn with you

Hope is not a plan

52

But, there is no plan without hope

Kedar S. Mate, MDChief Innovation & Education OfficerInstitute for Healthcare Improvement20 University Road, 7th FloorCambridge, MA

Department of MedicineWeill Cornell Medical College

[email protected] @KedarMate

Thank you

Citations

• AHRQ Health Care innovations Exchange. System-integrated program coordinates care for people with advanced illness, leading to greater use of hospice services, lower utilization and costs and high satisfaction. 2013. Available from: https://innovations.ahrq.gov/profiles/system-integrated-program-coordinates-care-people-advanced-illness-leading-greater-use

• Riley GF, Lubitz JD. Long-Term Trends in Medicare Payments in the Last Year of Life. Health Services Research. 2010; 45(2):565-576

• Field, Terry S., et al. "The costs associated with adverse drug events among older adults in the ambulatory setting." Medical care 43.12 (2005): 1171-1176.

• Health Research & Educational Trust (February 2017). Adverse Drug Events Change Package: 2017 Update. Chicago, IL: Health Research & Educational Trust. Accessed at www.hret-hiin.org

• Unutzer J et al. Healthcare costs associated with depression in medically ill fee-for-service Medicare participants. Journal of the American Geriatrics Society. 2009 Mar;57(3):506-10

• Rubin FH et al. Sustainability and scalability of the Hospital Elder Life Program (HELP) at a community hospital. Journal of the American Geriatric Society. 2013 Mar; 59(2): 359-365

• Wong et al. The cost of serious fall-related injuries at three midwestern hospitals. Joint Commission Journal on Quality and Patient Safety. 2011 Feb; 37(2): 81-87.

• Klein K, Bena JF, Albert NM. Impact Of Early Mobilization On Mechanical Ventilation And Cost In Neurological ICU. 2015 American Thoracic Society International Conference Abstracts.

56

https://innovations.ahrq.gov/profiles/system-integrated-program-coordinates-care-people-advanced-illness-leading-greater-use

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